Surgery for aortic stenosis in octogenarians: influence of coronary disease and other comorbidities on hospital mortality.

BACKGROUND AND AIM OF THE STUDY: Increasing life expectancy in industrialized countries and the high incidence of aortic stenosis (AS) in higher-age groups have led to wider indications for surgery in the elderly. The study aim was to re analyze operative risk factors, considering especially coronary status, for better patient selection and decreased risk.

METHODS

Between 1978 and 2003, 771 patients (319 men, 452 women) aged > or =80 years (mean 82.9 years) underwent valve replacement (bioprosthesis in 760 cases; 99%) for AS. Preoperative coronary angiography (performed in 617 cases; 80%) found significant lesions in 203 patients (33%) of either single- (n = 122), double- (n = 54) or triple- (n = 27) vessel disease. In total, 112 patients underwent associated coronary revascularization (one graft in 80 patients, and two or three grafts in 32).

RESULTS

Overall operative mortality was 10.1% (n = 78 patients). Predictive factors of mortality were left and right heart failure (p <0.001), emergency surgery (p <0.001), NYHA class IV (p <0.01), renal insufficiency (p <0.001), left ventricular ejection fraction (LVEF) <40% (p <0.01), atrioventricular block (p <0.01) and associated mitral valve replacement (p <0.01). Although no statistical difference was found, operative mortality increased according to the coronary status: no significant lesion 8.2%, single-vessel disease 11.5%, two-vessel 11.1%, and three-vessel 18.5%. If operative mortality is not influenced by single-vessel revascularization (10%), it becomes higher in multiple bypasses (18.8%).

CONCLUSION

Surgery remains the only treatment for AS. Since analysis failed to identify any specific high-risk groups, indications should remain broad and decisions made on an individual patient basis. A combined strategy associating angioplasty and surgery should be evaluated in order to improve the preoperative coronary status and reduce operative risk.